What do M1021 and M1023 require in terms of documentation?

The correct answer emphasizes the need for documentation of all primary and secondary diagnoses, particularly focusing on symptom control. In the context of OASIS-E, both M1021 and M1023 specify the importance of accurately capturing not just the primary home health diagnosis, but also any additional diagnoses that may impact patient care and treatment planning.

M1021 pertains to the identification of the primary diagnosis while M1023 expands on this by requiring documentation of any comorbidities or secondary diagnoses that might be relevant to the patient’s overall condition and care strategies, including how these conditions are being managed for symptom control. This holistic approach is critical for ensuring comprehensive care and understanding the full scope of patient needs, which is essential for effective treatment and outcome measurement. Therefore, documenting all relevant diagnoses helps healthcare providers to better assess the patient's situation, plan appropriate interventions, and monitor their progress throughout the home health care experience.